Ethical Aspects of the Guidelines for Medical Education for Students in their Clerkship Year at the Schulich School of Medicine and Dentistry During the COVID-19 Pandemic

Ethical Aspects of the Guidelines for Medical Education for Students in their Clerkship Year at the Schulich School of Medicine and Dentistry During the COVID-19

Guidelines for clerkship training at one Canadian medical school -Western University's Schulich School of Medicine and Dentistry -did not state the ethical principles associated with the decision to suspend and eventually resume clinical training during the COVID-19 pandemic.The absence of stated ethical principles was notable considering the impact these decisions had on various stakeholders, and since ethics plays a large role in the practice of medicine.This study assessed these guidelines using an ethical lens approach to identify ethical principles and tensions implicit in the guidelines.Clerkship is defined as the third year of training at this medical school, which consists of clinical rotations.While ethical principles were not documented, it was hypothesized that these could be identified within the guidelines.A literature search was conducted, which yielded a gap in knowledge concerning ethical considerations of clerkship clinical training.The guidelines were analyzed and ethical principles and tensions between conflicting principles were identified.The most prevalent principles were beneficence and non-maleficence.It is recommended that in the future, the ethical principles associated with guidelines responding to significant issues affecting undergraduate medical education be stated, in order to increase transparency to all parties involved, enhance communication with students, and to serve as an example of how ethics is applied in a medical education setting.One limitation of this study was the use of internal guideline documents, which were circulated internally but are not published.

INTRODUCTION
The COVID-19 pandemic caused disruptions to nearly all postsecondary education and training programs in Canada, including undergraduate medical education programs, all of which paused clinical training during the early months of the pandemic.This pause was of particular concern in light of the ongoing healthcare crisis, as disruption to medical education could impact negatively the filling of residency spots and the future availability of new physicians across the country -a vital resource for the continuing operation of the healthcare system.Medical schools in Canada are represented by the Association of Faculties of Medicine of Canada (AFMC), an organization that works to standardize medical education training and provides resources, advocacy, and guidance for schools.Their guidelines provided a framework for individual programs in their response to the pandemic as clinical experiences were paused and eventually resumed.The Council of Ontario Faculties of Medicine (COFM), which is a standing committee of the Council of Ontario Universities, works to ensure consistency and collaboration among the six medical schools in the province; and it adopted the guidelines from AFMC regarding clerkship during the COVID-19 pandemic.In turn, COFM's guidelines informed internal policies at Western University's Schulich School of Medicine and Dentistry's (Schulich).All of these guidelines were intended to safeguard students' health, as well as that of other healthcare providers, and to protect the limited supply of personal protective equipment (PPE) available in hospitals and healthcare settings at the time.Notwithstanding these protective measures for medical students, this pause in training caused them concern and distress about lost time in clinical training placements, missed opportunities for clinical experiences, and worry about how this pause would affect their competitive match to postgraduate training programs.Notably absent from these guidelines are outlines or evidence of discussion of ethical considerations inherent to the problems caused by the pandemic and proposed solutions.The AFMC, COFM and Schulich each issued their own sets of guidelines: COFM's guidelines were based on those from the AFMC, and Schulich's in turn were based on those of COFM.
The goal of this research is to identify and better understand the ethical aspects of the guidelines for clinical experiences as part of the medical education curriculum for Schulich's 3 rd year medical students during the COVID-19 pandemic.

BACKGROUND
There are many stakeholders in medical education: faculties of medicine, administrators, physicians, healthcare systems, and most importantly, the students.By examining the ethical principles and values that underpin the policies that affect students' experience, medical schools can ensure that the guidelines implemented will optimally support the institution's mission as well as their students.Ethics is at the core of all medical education, and ethical behaviour is an attribute that it strives to develop and strengthen in trainees.Therefore, it is desirable that the system that seeks to develop this quality in its graduates is itself self-reflective in this regard and governed by ethically sound principles.Through the analysis of the ethical considerations embedded in the AFMC, COFM and Schulich guidelines, our goal here is to highlight the principles that are just and ethically defensible, identify where these can be improved, and point out ethical tensions that exist.As ethical values were not explicitly stated, a gap in knowledge has been identified.Explicitly identifying the ethical considerations involved in or underpinning these documents would be a means of demonstrating transparency and accountability on the part of the school's administration, and also help to foster trust and acceptance in the students whose clinical training is governed by these guidelines.Furthermore, students would be more likely to follow these guidelines -because the guidelines ethically justify specific policy choices -and better supported in their training through an optimized provision of medical educational experiences adapted to a crisis situation, such as the COVID-19 pandemic.
A literature search was conducted through the Omni academic search tool. 1 In searching the keywords "Medical Students" AND "Clerkship Policies" AND "Ethical Principles" AND "Pandemic", 16 articles and book chapters were found including 2 duplicate results.None of these yielded applicable findings.When the search was modified to "Ethical Principles" AND "Clerkship Policies", 2 articles were found, although neither was useful.Other search terms were then tried: "Ethical Consideration" AND "Clerkship Policies" (1 article, not applicable), "Best Practices" AND "Clerkship Policies" (1 article, not applicable), and "Clerkship Policies" (9 results, none pertinent).The search was expanded to "Ethical principles guiding clerkship policies", which resulted in 247 articles and book chapters.Once again, none of these texts related to the subject of this inquiry.This literature search did not yield any scholarly articles for ethical considerations in medical school training or clerkship during a pandemic or during normal times.While disappointing, this lack of specific literature points to a need for an investigation of this topic.Nonetheless, we recognize that the use of one search engine is a limitation, and relevant publications may not have appeared in our literature search.This paper presents the findings from a specific subset of documents developed by AFMC, COFM and Schulich.These address the conditions for medical students' clinical training, and exposure to patients and healthcare settings.These documents do not list the ethical principles considered when creating the policy statements.A gap in existing knowledge has been identified with regards to the identification of the ethical principles that underlie the decisions made by these bodies which control the Schulich clerkship training activities.Apart from drawing attention to this deficit in knowledge, we undertook to identify the ethical principles which can be deduced from these positions, statements and guidelines.

METHOD
The method employed for researching this topic included a survey of the guidelines published by AFMC and COFM as they apply to clerkship, and the specific Schulich guidelines that derive from these, other applicable Schulich guidelines, and a literature review.This method involves descriptive, qualitative research employing primary sources.
As mentioned previously, the preliminary step in the project was a search of any available literature that was similar in nature to the research question.No published scholarly articles on the subject were found in 2020.As such, the literature review for this project only included the relevant AFMC, COFM and Schulich guidelines.
Themes identified from healthcare workers' experiences during the 2002 SARS pandemic are applicable to this research (1).It was determined that an ethical lens approach was best for this project, as opposed to using a specific ethical framework.This approach is described as the conscientious attention to ethical considerations (2).There are many ethical principles, which are fundamental tenets which form the basis of reasoning or action (3) involved in the material examined, and to limit the review by focusing only on a particular set of principles would unduly constrain the analysis.Documents were analyzed using the lenses of principlism, ethics of care, and virtue ethics.

FINDINGS
Ten documents were reviewed for this study (Table 1).Among these were three statements released by COFM, one by AFMC, five Schulich internal memos and letters, and one Schulich position statement.While the AFMC documents had been available for open access online, the remaining documents were circulated internally by email to the target audience: students, academic leadership and staff.One of the authors (CMG) was on the distribution list for these documents in accordance with their role as Clinical Education Team Leader2 .The Associate Dean, Windsor Campus, granted approval for review of these documents and the themes therein for the purpose of this project 3 .All emails received by Christine Gignac Ethical principles were not listed in any of these documents, which address the circumstances of clerkship during the COVID-19 pandemic, notably the initial pause when students were removed from clinical settings, and as considerations were made in the circumstances that would permit them to resume their training.The identified lack of communicated ethical principles occurred during all phases of the timeline within the scope of this paper, i.e., both early in the pandemic in March 2020 and through the summer when the clerkship pause was lifted, and students returned to their clinical rotations on July 6, 2020.Some common themes, however, were apparent.A few of the documents listed these as "Guiding Principles".The guidelines were written primarily as instructions to be followed and steps to be taken.As such, it cannot be known whether direct mention of ethical principles was discussed in the creation of these guidelines.Given that the authors were, for the most part, physicians, whose profession is centred on ethical practice, it is not unimaginable that ethics was indeed a part of this process.So, while not explicitly stated, it is still possible to infer ethical principles from the information outlined in these documents.
The most prevalent theme in these documents was student safety, with six of the texts including this among their principles for a return to clerkship.The associated ethical principles are mainly beneficence and non-maleficence.Safety was cited as the reason for the clerkship pause, the continuation of the pause, a proposed date of return to the clerkship, and the conditions that must be present for clerks to safely return to the clinical environment.The benefits of permitting students to return to the clinical environment by necessity would have to outweigh the risks (4).Beneficence is also evident when ascertaining that occupational health guidelines were in place for student safety (4).At the outset of the pandemic, if a clerk had been in contact with a patient who later tested positive for a COVID-19 infection, a process was outlined to ensure appropriate steps were followed which included the clerk self-isolating and contacting Public Health (5).Concern for students' mental health was also addressed in these documents.In addition to beneficence, this demonstrates the ethical principle of reciprocity.There was an acknowledgement of the stressful situation this created for students.The Ontario Deans of Medicine acknowledged in their "Joint Statement to all Ontario Medical Students" document the uncertainty over when the students would resume their clinical training (6), and stress in the learning environment (7) was cited.Support services through the Learner Equity and Wellness Office were recommended to clerks (8).
COFM's measure to allay mounting uncertainty and stress was to establish a common "earliest possible" date for resumption of clinical placements (4).Physical concerns were allayed by ensuring students' return would be safe and PPE was provided.Mental health concerns were addressed by working to get clerks back to clinical placements as quickly as possible.Students were encouraged to contact support services through the Learner Equity and Wellness Office.Table 2, below, outlines the details of how specific factors should be addressed with regards to student safety.
Equality was the next most common theme, with five of the documents alluding to this consideration.The prevailing context for this theme was to emphasize that although the altered clinical training experience brought about by the pandemic may be seen by some students to be inferior due to the absence of some rotations and procedures that previously were available, the six medical schools in Ontario had agreed to all follow the same set of guidelines and conditions.In so doing, no school or group of students within the province of Ontario could be seen to have an advantage over others.For example, all Ontario medical schools agreed to return to clerkship training within the same general timeframe if not the exact same date (6).In addition, a "Key Principle Statement" in one of the COFM statements outlined that students were not to seek out experiences "outside of approved curricular activities", both because of liability, as they may not be covered by malpractice insurance, and also to not gain an advantage over other students (9).
Other common themes found in these documents were patient safety, and restriction of choice, both with four counts each.Patient safety, demonstrating the values of beneficence and non-maleficence, was a consideration primarily in the documents that provided guidance on a return to clerkship.Having the students present and interacting with patients in care settings could occur as long as the overall benefit to patients outweighed any potential risk.
The ethical values of proportionality, duty to care and social responsibility are evident here.Restriction of choice describes occasions where clinical learning opportunities and environments are limited due to the pandemic.This involves the principle of autonomy in conflict with other values as seen in the students' restriction of choice.Some examples of this are rotations such as Emergency Medicine that might expose clerks to COVID-19 positive patients, or specific procedures, for example intubations, which cause exposure to aerosolized bodily fluids that pose a higher risk.Limitation in the locations students could choose for their electives was also outlined, as schools closed their doors to accepting students from other medical school programs.Before the pandemic, medical students nationwide could choose elective placements in any medical school location across Canada -these were now limited to rotations within their home school.
Concern over the availability of adequate PPE worldwide was a major reason for removing clerks from clinical settings early on.The ethical values associated with this are justice, and prudent use of resources.One of the factors for resuming clerkship was the ability to ensure that clerks would be provided with an adequate supply of PPE as outlined by local infection control and prevention bodies (non-maleficence).Additionally, students could not return to clerkship unless they were trained on how to properly use the PPE (beneficence) (7).
Three of the documents listed "Guiding Principles".Most of these principles were the same, with differences arising as the guidelines moved from a national scope to a local one.For the AFMC and COFM, the Key Principles were comprised of the themes mentioned above (patient safety, student safety, safety of teaching faculty and hospital staff, learning, supervision, and consistency).The Schulich document (9) lists eight guiding principles and outlines procedures for students, faculty, and programs to follow, and restrictions on students' clinical experiences to be observed.For example, students ought not to participate in any activities organized by postgraduate programs, so that they would not be seen to gain an unfair advantage over other students.

RECOMMENDATIONS
Our principal recommendation is that the ethical principles that were implicit in the documents reviewed be made explicit in future guidelines.When ethical principles are visibly included in the decision-making process in extraordinary circumstances, such as the COVID-19 pandemic, it helps to promote understanding, trust and transparency among the individuals affected by the process.Changes to clerkship training were made primarily at the outset to protect the health and ensure the safety of students.As the pandemic continued over the following months, other factors were considered, notably patient and staff safety as a return to clerkship training in the clinical environment was in the planning stages.The issue of clerkship training during the pandemic was highly complex and presented more challenging issues than initially thought.Including the ethical principles that underlie changes resulting from a pandemic situation can encourage dialogue and provide checks and balances to ensure leadership makes the best decisions possible during challenging situations.Secondly, we encourage institutional leaders -and those responsible for drafting guidelines -to identify ethical principles and conflicts between them when creating guidelines that can significantly affect students' training experience.Addressing the ethical principles would be a starting point for integrating ethics into guidelines addressing issues relating to undergraduate medical education, and clerkship in particular.
The ethical principles most evident in the documents reviewed are beneficence and non-maleficence.Beneficence is applied in the desire by leadership to ensure the safety of the students, physicians, patients, and other professional staff.Nonmaleficence is evident when considering the re-entry of students to the clinical learning environments and weighing whether the risks of potential COVID-19 exposure outweigh the benefits of resuming training.And it also applies to patients, to ensure the clerks are reintegrated in a safe manner that does not endanger patients under their care.The principle of justice is seen in the efforts across the various organizations to maintain equity for medical learners, so that none are given opportunities that are unavailable to others.This principle also applies when considering the impact on resuming clerkship training and having students back with physicians and patients, as the interests of each of these groups also must be considered.The wise use of resources is a component of justice and was applied early on in the pandemic when adequate supplies of PPE was an issue.Students' medical school journey was severely restricted, both in terms of choices of electives and in the freedom to partake in all the procedures and clinical experiences that are normally a part of clerkship.Here we see a tension arise as leadership sought to balance the public health restrictions caused by the pandemic (beneficence, nonmaleficence and justice) with permitting students to have as wide a breadth of clinical experience as possible, out of respect for their autonomy.
In addition to these principles, several other notable values are evident in these guidelines.For example, ethical principles that have a theological dimension and are important in Catholic Health Care Ethics were also present.Solidarity, for example is an ethical principle found in several of the documents and was evident in the descriptions of the governing bodies in their attempt to ensure fairness and equity for learners across the province.This speaks to the dignity of and respect for persons, in this case the learners.Virtues serve to perfect the moral agent with the aim of achieving certain goods (10).Prudence speaks to caution and considering all available information when making decisions.The virtue of justice enables its possessor to discern the best actions and choices for the circumstance.Stewardship, which is connected to the virtue of justice, applies to resource utilization (10).The common good, which involves the good of society ( 11) is also a component of the virtue of justice (12).Solidarity and beneficence are both expressions of the virtue of charity (12).These are important as part of Schulich medical students' training in Ontario takes place at Catholic-sponsored healthcare institutions.Some common themes were apparent.Table 2 lists the ethical values that correspond with the themes and principles identified in the documents.To demonstrate how ethical principles can be applied in the decision-making process, the table from the UE: COFM Principles and Process for Determining Resumption of Clinical Activities (3) has been amended by adding a column that lists the associated ethical values (Table 3).

Consistency
Given the accepted principle of alignment of all Ontario schools, can the above be achieved for all at this time?
• Although exact synchronization of return dates may not be possible given varying clerkship structures and impact of the pandemic, schools will strive to coordinate and minimize discrepancies.

CONCLUSION
This study explores and describes the ethical considerations for the pause and eventual resumption of clerkship training for medical students at the Schulich School of Medicine and Dentistry during the 2020 COVID-19 pandemic.In the early weeks of the pandemic, medical students were left with many questions about what their journey to becoming doctors, in a context where their expected path was abruptly halted.This liminal experience will profoundly shape the practice of this cohort of medical students.These clerks found themselves in an unexpected space where their clinical training ended abruptly, and they were left waiting for an uncertain future.This was uncharted territory, not only for these students but also for the physicians who supervised them, their families and friends, and society at large.And it was a difficult time for everyone, particularly those working in healthcare.It can be argued that this situation affected clerks in a unique way, because they were left on the sidelines while many of the physicians who supervised them were continuing to work every day, courageously battling this disease and saving lives.The clerks were excluded from this experience, while trainees just a few years their senior were able to continue their residency training experiences.In light of this situation, and the fact that these students had paid significant tuition fees, to not be allowed to participate in the medical community as they expected to, and to not even know what to expect going forward, affords them special consideration in this circumstance.
The administrators whose decisions marked the pause and resumption of clerkship had a significant influence on these students.There was no explicit evidence of ethical consideration regarding these decisions in the guidance documents outlining changes to the clerkship experience; nonetheless, our analysis pointed to a series of ethical principles that implicitly underpinned these documents.So, while it can reasonably be presumed that these principles were unconsciously applied by those responsible for managing the clerkship during the pandemic, a reliance on the implicit ethical virtues and good judgment of professionals and decision-makers is clearly insufficient for good governance.It is thus recommended that in the future administrators explicitly include the corresponding ethical principles alongside the guiding principles they propose,

Table 1 : Description of study documents
UG:COFM and PG:COFM Joint Statement on Medical Student Clinical Experiences.Council of Ontario Faculties of Medicine, Approved by COFM Deans 26 Aug. 2020.

Table 3 : Ethical values in the UE COFM Principles and Key Considerations
• Can continuing oversight of learners be provided • Can learners be assessed?• Are these available in all areas necessary to provide a full clerkship experience?Solidarity Equity